A practical tip for intraoperative perforator vessel selection: Portable thermal imaging

In planning of free-style free perforator flaps, relying on defined anatomical landmarks and preoperative imaging technologies is difficult to locate the perforating arteries. Situation gets more complicated when encountered multiple perforating arteries enter the small skin paddle. In these situations, the ideal perforator has to be selected mostly by clinical inspection. We would like to share our method for selecting the ideal perforating vessel in free-style perforator flaps by utilizing portable thermal camera, which may be a reliable intraoperative adjunct. An index digit soft-tissue reconstruction was planned with a free posterior interosseous artery flap. Preoperatively, two perforators were marked on intermuscular septum. After the skin island is elevated totally, both of the arteries were found to be of similar by means of caliber (<0.8 mm) and pulsation. A cold challenge test was applied to flap and a continuous video record with thermal camera was taken for 1 min. Video record shows that the dominant perforator is the distal one. Thus, the flap was raised based on distal perforator. Postoperative follow-up was uneventful. The portable thermal imaging is a low cost and readily accessible intraoperative adjunct for selecting the dominant perforator in free-style perforator free flaps.